Alcohol-related hospital admissions are high in England and Lewisham and are rising6.

England has one of the highest liver disease death rates in Western Europe and it is the only disease where the death rate among those under 65 has been rising7.

In 2003, the World Health Organisation (WHO) found that alcohol accounted for 4% of all disease burden worldwide (excluding many indirect health consequences)8.

The WHO estimates that the total amount of alcohol consumed in litres of pure alcohol in the UK adult (15+) population per capita is 13.4, this is compared with the European region average of 12.2 litres9. Alcohol consumption has increased over the last decade and recent estimates show that over 70% of adults in Britain drink alcohol, with 31% of men and 20% of women consuming in excess of 21 and 14 units on a weekly basis, respectively10. Around 25% of males and 15% of females may be classified as hazardous or harmful alcohol users11.

Over 24% of the English population, (33% of men and 16% of women), consume alcohol in a way that is potentially or actually harmful to their health or well-being at a level associated with a range of health, crime and economic outcomes. Men who regularly drink over 50 units per week (or eight units per day) and women who regularly drink over 35 units per week (or six units per day) are most at risk of developing alcohol-related illness or injuries or being admitted to hospital.

Alcohol dependence affects over 1 million people, 4% of the population aged between 16 and 65 in England (6% of men and 2% of women) however, only about 6% per year receive treatment. Reasons for this include the often long period between developing alcohol dependence and seeking help, and the limited availability of specialist alcohol treatment services. Additionally, alcohol misuse is under-identified by health and social care professionals, leading to missed opportunities to provide effective interventions12.

Alcohol misuse is also an increasing problem in children and young people, with over 24,000 treated in the NHS for alcohol-related problems in 2008 and 2009.

2.4 million Londoners drink at levels that are ‘harmful and hazardous’13.

Alcohol misuse in England in 2004 was estimated to cost between £18-25 billion a year on alcohol related disorders and diseases, crime, loss of productivity in the workplace and health and social problems experienced by those who misuse alcohol and their families14. The cost of crime/public disorder was estimated to be up to £7.3bn in 2004 and includes the cost to services in anticipation and as a consequence of alcohol-related crime, the cost to criminal justice system, the cost of drink-driving, and the human costs of alcohol-related crime. The cost of alcohol-related harm to the workplace was estimated to be up to £6.4bn pounds. The estimated cost to the NHS alone of the harmful use of alcohol (regularly drinking at increasing or higher risk levels) is around £2.7 billion in 2006/7 prices15.

Alcohol Consumption

Alcohol drinking definitions: The way in which alcohol consumption has been defined has recently changed. Both frameworks are included here to help the reader understand the references to alcohol consumption used throughout this document.

Levels of alcohol consumption (and associated harms) have changed over the last decade and so updated estimates are necessary to understand the current situation. A recent report presents new synthetic estimates of increasing risk drinkers (previously referred to as hazardous drinkers) and higher risk drinkers (previously referred to as harmful drinkers) at local authority level in England for 2008 and, for the first time, also includes estimates of the number of abstainers and lower risk drinkers in each local authority. These estimates should be used in conjunction with local intelligence about alcohol use.

It is estimated that fifteen percent (31,873) of the Lewisham population are ‘increasing risk’ drinkers, which is similar to London. Higher risk drinkers in Lewisham number 11,365, which is 6% of the population and is lower than the London average. Although more than one fifth (46,029) of the Lewisham population abstain from drinking, which is lower than London, just over 57% (118,194) are lower risk drinkers, which is higher than the percentage for London.

Binge Drinking
Binge drinking in the general population can be difficult to quantify; partly because the definition of binge drinking is not consistent, and also because different patterns of drinking do not tend to be evaluated as separate entities18. Binge drinking is more prevalent among men than women, and more prevalent among young people19. The 2004 Health Survey for England showed that younger people were more likely than older people to exceed the daily benchmark limits of alcohol, but less likely to drink every day20. The evidence supports the suggestion that binge drinking is a problem affecting mostly young people21.

The estimated percentage of the population aged 16 years and over who reported engaging in binge drinking during the three year average period 2003/05 for Lewisham was 13%. This was lower than England, but not significantly different from London during the three year average period, 2003/0521.

Alcohol consumption among Children and Young People
The results below are from a sample of primary and secondary pupils in Years 2, 4, 6, 8 and 10 in Lewisham who were surveyed in 2010 . The survey is undertaken every 2 years. Forty percent of pupils aged 6 to 7 (Year 2) reported that they had tasted alcohol.

Primary school pupils in Years 4 and 6 (ages 8 to 11 years):

7% of pupils said that they drank an alcoholic drink (more than just a sip) on at least one day in the week before the survey

65% of pupils say that they don’t drink alcohol. 4% of pupils reported that their parents ‘never’ or only ‘sometimes’ know if they drink alcohol

28% of pupils reported that their parents always knew if they drank alcohol

1% of pupils drank beer or lager, 2% said wine, 1% said spirits in the week before the survey

Secondary school pupils in Years 8 and 10 (ages 12-13 & 14-15 years):

16% of pupils drank alcohol on at least one day in the week before the survey

Wine and spirits were the most popular drinks

8% of pupils drank alcohol at home and 6% drank at a friend’s or relation’s home. 3% of pupils drank alcohol outside in a public place

1% of pupils bought alcohol from a supermarket and 2% from an off licence who should only sell to over-eighteens

2% of pupils drank alcoholic drinks in a pub or bar who should not be serving alcohol to under eighteens

Lewisham secondary pupils were less likely to have drunk alcohol in the previous week compared with the wider sample of the survey. Twenty three percent of Year 10 boys stated that they drank alcohol in the week before the survey compared with 30% of the wider sample, 16% of Year 10 girls drank alcohol compared with 29% of the wider sample.

Impact of Alcohol on Death, Disease and Disability

Deaths from alcohol
Deaths from alcohol provide a measure of the impact of alcohol. There is a direct dose-response relationship between alcohol consumption and risk of death24. The main sources of information considered here are: alcohol-attributable deaths; deaths due to chronic liver disease; and suicides 25.

Deaths from liver disease are a useful marker for alcohol related harm. It is of concern that England has one of the highest death rates from liver disease in Western Europe and it is the only disease where the death rate among those under 65 has been rising (Figure 1).

Figure 1
Source: London Health Improvement Board Nov 2011

The mortality rate from chronic liver disease for men and women under 75 in Lewisham was not significantly higher than London and England in the three year period from 2007 to 2009. There were a total of 66 deaths under 75 in Lewisham during this period, twice as many early deaths for men (44) as for women (22)27 (see Appendix 1 by clicking on Supporting documents).

Suicides and Alcohol
In Lewisham there were only three records with alcohol or alcohol intoxication as a cause of death for all deaths from April 2004 to Dec 201028with a verdict of suicide/took own life or an open verdict. In contrast, information available about alcohol and suicides from 76 GP case notes during the 5 year period 2002/7, (which were analysed as part of the Lewisham Suicide Audit)29 showed that almost a third (24 of the 76) had a record of alcohol use. There was variation in the GP recording, so alcohol was probably under-reported.

Alcohol-related Hospital Admissions
Alcohol related hospital admissions are a proxy indicator for alcohol morbidity, providing an indication of the public health effects of alcohol. There are a number of ways of looking at alcohol-related hospital admissions. These differ in the kind of admissions data they incorporate, as well as the amount of weight they give to each individual admission. This section includes an analysis of the National Indicator 39 (NI 39) alcohol attributable admissions30 and alcohol-specific admissions. Definitions of these measures are given in Table 3.

Table 3: Definitions of alcohol related admissions

Each of these admissions can be presented as a rate (directly standardised per 100,000) or as persons admitted.

NI 39: Alcohol-attributable Hospital Admissions:
The advantage of alcohol-attributable admissions (NI 39) is that the use of directly standardised rates allow for comparison across England, London and with other geographical areas and provide a general picture of alcohol-related admission trends31.

The rate of NI 39 admissions is high in both England and Lewisham. Since 2002 alcohol-related admissions (NI 39) in Lewisham have been increasing in line with patterns for England. However, since 2006/07 the rate of increase in alcohol-attributable admissions in Lewisham has been declining. In other words, although alcohol-attributable admissions continue to rise, the rate at which they do so has now slowed down. More information about alcohol-attributable admissions can be found in the ‘Performance and Targets’ section of this document.

Alcohol-specific hospital admissions:

The analysis of alcohol-specific hospital admissions is also helpful in assessing the impact of alcohol. Alcohol specific admissions for men in Lewisham are not significantly different from those for England, however, alcohol specific admissions for women and those under 18 are significantly less than for England32.

Figure 2

The alcohol specific admissions rate has been rising in Lewisham since 2005/6 (Figure 2). Alcohol-specific diagnoses can be categorised into three main groups based on the dominant diagnosis: chronic conditions, mental and behavioural conditions, and acute conditions33. The majority of alcohol-specific admissions in Lewisham fall into the mental/behavioural admissions category34. On average, admissions for mental/behavioural conditions constitute nearly three quarters of alcohol-specific admissions; chronic conditions constitute nearly a quarter and acute conditions just five per cent of total alcohol-specific admissions. This pattern is relatively consistent, with a slight variation from year to year (see Appendix 2 by clicking on Supporting documents)

Accident and Emergency Data
The use of Accident and Emergency Departments, including the number of Accident and Emergency attendances and the number of alcohol-related call-outs to the London Ambulance Service is another indicator of alcohol morbidity. Seventy percent of A&E attendances at peak times are the result of alcohol use35. For the past three years there have been more than 1,000 alcohol-related call outs per annum (3% of the total), with little variation in the number of call outs per year (Table 4).

Table 4

Impact of Alcohol on Wider Determinants
Alcohol use has a major impact on health, anti-social behavior, crime and other important social issues, including the well-being and development of children36.

Alcohol-related Fire
Alcohol is a suspected factor in 1 in 18 of all-dwelling fires in Lewisham, and in 1 in 12 of all dwelling fires in Lewisham where people are involved (either as a fatality, casualty, or rescue). This is lower than the London average of 1 in 7 accidental fires where people are involved. The London Fire Brigade reports37 that there is a correlation between the days of the week when people who drink are most likely to consume the most, and the days of the week when more dwelling fires happen (Sunday, Saturday and Monday).

Alcohol-related Crime
Many of those injured as a result of alcohol-related crime and disorder are likely to present, in the first instance to A&E departments. There are also health impacts on victims of alcohol-related crime and disorder such as domestic abuse, assault or drink-driving and many who repeatedly commit alcohol-related crime and disorder may be involved in a pattern of drinking which could be increasing risks to their long-term health38. According to the London Probation Trust, alcohol is associated with offending in one third of the caseload39. There were 93,000 crimes attributable to alcohol (2009/2010) in London40.

Figures 3 & 4

Over the past 5 years the rate of alcohol-related recorded crimes in Lewisham has remained the same, with a slight reduction over the period. However, Lewisham is significantly worse than the England average and the average for all the London local authorities (Figure 3). Again, Lewisham has a significantly higher rate of alcohol-related violent crimes than England and the rate has remained more or less the same over the past five years, with a slight reduction41 (Figure 4).

Figure 5

The rate of alcohol-related sexual offences in Lewisham per 1,000 of the population, whereby the arrestee tested positive for alcohol has remained the same with a slight reduction over the past five years (Figure 5). It is also significantly higher than England42. A UK study showed that 51% of respondents from domestic violence agencies claimed that either themselves or their partners had used drugs, alcohol and/or prescribed medication in problematic ways in the last five years43.

Figure 6
insert chart here

Figure 6 shows the numbers of victims of sexual assault who received support from the Havens, Camberwell. It shows clients from Lewisham who had used alcohol at time of assault44. The number of Lewisham residents recorded by the Havens, who have been sexually assaulted has decreased by almost a third from 2007 to 2010, however the proportion of cases where alcohol was flagged as involved has increased year by year over the same time period. This may be due to increasing awareness of the need to record alcohol consumption.

Figure 7 shows that Lewisham has had consistently lower numbers of drink-driving arrests than the neighbouring boroughs of Lambeth and Southwark. There has been a reduction in the number of arrests from 2005 to 2010 across all 3 boroughs45.

Street Drinkers
Street drinking has been an issue in Lewisham for sometime, but over the last three years, complaints to the Mayor, Council Members and Officers and the Police from both residents and traders have increased in frequency and frustration. A number of areas in Lewisham were identified as facing significant challenges in reducing the nuisance caused by street drinkers. These were: Deptford; Rushey Green; New Cross; and Sydenham. Police data was analysed, alongside data from Safer Neighbourhood Teams and officers on confiscations, arrests, warnings and Met Police Computer Aided Despatch (CAD) calls. Wards with street drinking problems include Sydenham, Lewisham Central, Rushey Green and New Cross, where the powers have been used regularly, while the 10 wards have not used the powers at all46.

Housing and Homelessness
Forty seven percent of accommodation service users of St Mungo’s (an agency working with rough sleepers, homeless people and vulnerable adults at risk of homelessness in London) had alcohol problems in 200947.

Social housing

The number of tenants in social housing in Lewisham with severe alcohol problems is unknown. However the impact of tenancy breakdown on housing staff resources and input is considerable. In addition, problem drinking may cause stress and discomfort for neighbours and the community in general. Vulnerably housed tenants with alcohol problems may suffer from stigma, lack of services and sometimes violence against them.

Single Homeless Intervention and Prevention (SHIP)

This service is a housing options centre for single people in Lewisham who are homeless or are worried they might become homeless. It acts as a single access point for single people requiring homelessness prevention and supported housing services and attempts to resolve peoples’ housing problems and thus prevent homelessness, whilst ensuring that support services and supported housing services are available to those people who need them. The total number of people presenting to SHIP with ‘alcohol issues defined as primary and secondary needs’ has increased from 137 in 2009/2010 to 160 in 2010/2011. Over both reporting periods, the most common outcome for presenting clients with primary and secondary alcohol needs was Closed –Supported Housing. More men than women accessing SHIP presented with alcohol related needs. In 2009/2010, most people accessing SHIP were 35-44 year olds and in 2010/2011 were 45-54 year olds. In 2010/11, 70 of the 2,222 (3%) people living in ‘Lewisham Supporting People Accommodation’ had ‘alcohol problems’ as their primary support need. Most young people accessing treatment with the Crime Reduction Initiative (CRI)/New Direction, (the specialist substance misuse agency) live in rented accommodation, however, thirteen individuals reported having an accommodation need 28 days prior to treatment start, including 8 with ‘No Fixed Abode’.

Safeguarding Children and Young people
Alcohol is a major concern regarding the safety and well being of children and young people. It is difficult to estimate how many children are affected by parental substance misuse. Anecdotal evidence from professionals in Lewisham suggests that parental alcohol use is a growing problem across the borough48. There is much variation in the effects of substances on individual users and their families. Also, many children hide parental substance use as well as hiding from it49, and the fear of what will happen to them and to their parents prevents many from sharing their experiences. Parental substance misuse can cause considerable harm. Children are more likely to develop emotional, behavioural and social problems, use substances themselves, and become educationally and socially excluded50. In Lewisham in 2010/11 53% of individuals in alcohol treatment with CRI (New Direction) reported being a parent, with 27% of parents having children51 living with them. In the same year, 35 of the 89 cases of domestic violence, where drinking was flagged as a concern, involved children52. The designated safeguarding doctor for Lewisham Healthcare Trust reported that there were 27 presentations of children under 16, 35 aged 16-17 and 20 aged 18 years with a diagnosis of alcohol related problems in 2010. In 42.3% of all referrals to the Hidden Harm Co-ordinator, alcohol is the primary substance, it plays a part in 57.6% of the total referrals. Twenty eight to thirty three percent of all Children's Social Care cases involve parental substance abuse, each case has an average of 2 children affected and 57% of the cases are Child protection53.

Cost of Alcohol
The estimated £18 billion to £25 billion54 a year cost of alcohol misuse spans alcohol-related disorders and disease, crime and anti-social behaviour, loss of productivity in the workplace and problems experienced by those who misuse alcohol and their families. For the NHS alone, the estimated financial burden of alcohol misuse is around £2.7 billion55 in hospital admissions, attendance at A&E and in primary care. Alcohol-related illness or injury accounts for 863,000 hospital admissions per year. Recent studies suggest that alcohol treatment has both short and long-term savings and analysis from the UKATT Study suggests that for every £1 spent on treatment, the public sector saves £556. Alcohol contributes to the London economy, but its economic costs are estimated at £2.5bn per year57. The estimated total economic costs to Lewisham far outweigh the small intervention and treatment budget of £2.6m. The estimated annual cost of Lewisham hospital alcohol-attributable admissions was £10 million. The average annual cost of alcohol related ambulance call outs is £300,000 for Lewisham58.

References

London Health Improvement Board November 2011

ibid

ibid

NW England Public Health Observatory, Topography of Drinking Behaviours in England, August 2011

School Health Education Unit, Supporting the Health of Young People in Lewisham. A Summary Report of the Health Related Behaviour Survey, 2010

White et al., 2002

Deaths from alcohol-attributable conditions (all ages, male/female), directly standardised rate per 100,000 population (standardised to the European Standard Population). (NWPHO from Office for National Statistics Public Health Mortality File for 2009 and mid-year population estimates for 2009).

This was the key national performance indicator for alcohol. It is expressed as the rate of alcohol attributable hospital admissions per 100,000 of the population - likely to be retained within the new Public Health Outcomes Framework

In England, alcohol-attributable fractions (AAFs) are annually applied to Hospital Episode Statistics (HES) by the North West Public Health Observatory (NWPHO)

The cost of alcohol-related harm to the NHS in England, Department of Health, 2008), Gateway 10277

UKATT Research Team (2005). Cost-effectiveness of treatment for alcohol problems: Findings of the UK Alcohol Treatment Trial. British Medical Journal, 331:544–547

ibid

The cost of an ambulance call out is £225. This means that the estimated cost of alcohol-related ambulance call-outs for 2010/2011 was £296,100, for 2009/2010 was £307,800, and for 2008/2009 was £309,825.